Management of acute lower limb ischemia following percutaneous arterial closure device application: our experience.

INTRODUCTION: The Authors report their experience in the management of acute lower limb ischemia following percutaneous arterial closure device application. PATIENT AND METHODS: Five patients required an emergency vascular operations for acute lower limb ischemia. The symptoms onset was < 1 hour in 1 case, 4-12 hours in 2 cases and > 24-36 hours in 2 cases. A preoperative angiography was performed in all the cases. A transfemoral embolectomy was carried out. Direct suture repair were performed in three cases, vein patch angioplasty was carried out in two cases. In one case, a common femoral artery endarterectomy was performed. RESULTS: No post-operative mortality and limb loss occurred. CONCLUSIONS: Acute lower limb ischemia due to closure devices required an extensive approach with reconstruction in high risk septic area. Angiography is mandatory for surgical strategies. We prefer direct suture repair and vein path angioplasty for vascular reconstruction.

Indications and results of endovenous laser tratment (EVLT) for greater saphenous vein incompetentce. Our experience.

AIM: Endovenous laser treatment (EVLT) seems to be a safe and less invasive method for the treatment of the great saphenous vein (GSV) incompetence. The aim of our study was to evaluate the indications and results of EVLT. METHODS: Between January 2003 and October 2004, 77 patients (55 C3 and 22 C4) underwent EVLT. In 23 cases phlebectomy was performed, in 16 patients a subfascial perforator vein ligations occurred. In 62 patients we used a percutaneous access to the distal GSV, in 15 cases a surgical isolation was performed. In all cases a 600 nm with 1 mm diameter laser was used. RESULTS: Follow-up was performed for a period of 6 months and showed GSV recanalization in 2 cases; 18 patients (23.3%) developed a transient postoperative pain along GSV, in 4 (5.1%) of them the pain persisted for 3 months. In 6 cases a reversible paresthesia due to a lesion of the saphenous nerve were recorded (7.7%) and in 1 case (1.2%) a skin burn occurred. No deep vein thromboses were observed. CONCLUSIONS: EVLT is a safe technique, with low incidence of recanalizations and postoperative complications. Our opinion is to extend the indication in selected cases of GSV incompetence.

The role of popliteal artery embolectomy in the management of acute lower limb ischemia: our experience.

INTRODUCTION: The Authors report their experience in the management of acute lower limbs ischemia through distal popliteal artery approach. PATIENTS AND METHODS: Five popliteal embolectomy through a medial approach were performed; in one patient a posterior approach was carried out. Patients were included in two groups on the basis of ischemia duration: group A<6 hours (3 patients) and group B>6 hours (3 patients). Colour-duplex scan was performed in all the patients The arteriotomy was closed with interrupted 7/0 monofilament polypropylene sutures. RESULTS: There were no peri-operative deaths. The primary limb salvage rate was 83.3% (5 patients). In one case (16.7%) a major amputation was performed. In one case (16.7%) a drop foot occurred. CONCLUSIONS: The popliteal embolectomy is followed by excellent results and should be consider prior to thrombolysis or bypass graft revascularization. An appropriate use of duplex scan and a medial approach can lead to an high successful rates in terms of limb function and limb salvage also in cases with delayed ischemia.

Rupture of an isolated true superficial femoral artery aneurysm: case report.

True isolated atherosclerotic aneurysm of the superficial femoral artery is a rare pathology. We report a case of ruptured superficial femoral artery aneurysms (SFAA) not associated with aortic, common femoral or popliteal artery aneurysms. An emergency surgical procedure was performed and, after endoaneurysmal branches ligation, a ePTFE graft interposition was performed. The literature review shows a prevalence of rupture as compared with ischemic complications and the need for surgical repair in case of SFAA with diameter twice the normal vessel size. Early diagnosis and management are recommended because of the lower morbility and mortality rates associated with elective surgery by comparison with emergency procedures.

[Penile ultrasonography. Characteristic velocimetric feature in the maximal erection phase in healthy subjects]. / Eco color-Doppler penieno. Caratteristico aspetto velocimetrico nella fase di massima erezione in soggetti sani.

BACKGROUND: A peculiar finding from penis eco color-Doppler, detected in healty subjects with erection dysfunction, is described. METHODS: 385 patients with erection dysfunction were studied, by using duplex scan with color Doppler, 85 of these patients normal Regiscan test were chosen and patients with Induratio penis plastica or hormonal disorder were excluded. RESULTS: A "reverse" flow during the entire diastolic phase was detected in 58 normal patients (68%) with age < of 41 years. CONCLUSIONS: In the evaluation of healthy subjects with erection dysfunction, the presence of a complete "reverse" diastolic flow is indicative of a venous reflux block, that may represent an important pathogenetic mechanism in this specific setting.

[Surgical endoscopy of the airways]. / Endoscopia operativa delle vie aeree.

METHODS: Between April 1993 and April 1996, 146 endoscopic procedures were performed in 128 patients (144 with Nd:YAG laser) with benign or malignant obstructions of the airway. Removal of foreign bodies are not included in this series. Twenty resections were performed with the flexible fiberoptic bronchoscope under local anesthesia and 126 with the rigid tube under general anesthesia. Power settings were always between 20 and 35 Watts. Eighteen procedures were performed in emergency. Fifteen patients had a benign postintubation tracheal stricture (20 treatments-11 Dumon stents and 1 Montgomery tube). Eighty-two patients (90 treatments-12 stents) had malignant lesions of the airways (trachea 11, carina 2, RMB 22, LMB 27, TI 11, LULB 3, RULB 2, LILB 4). Laryngeal, tracheal or bronchial granulations were present in 19 patients (21 treatments). Other lesions were present in 11 patients (14 treatments-6 stents). RESULTS: Major complications occurring during laser resections were bleeding (2), hypoxia (1) and cardiac arrhythmia (2); 2 patients died 24 hours after the procedure for cardio-respiratory failure. The airway calibre was improved in 100% of patients with benign lesions and 82.4% of patients with malignancy. In the latter group the trachea, main stem bronchi and truncus intermedius calibre was improved better than the lobar bronchi. All patients with malignancy underwent chemo-radiotherapy without respiratory distress. CONCLUSIONS: Nd:YAG laser therapy is a safe and effective mean of releasing airway obstructions; indwelling stents contribute to further improve the results.

Technique to reduce air leaks after pulmonary lobectomy.

OBJECTIVE: Patients undergoing pulmonary resections often present postoperative air leaks of varying magnitude and duration; this complication is more frequent with incomplete or absent interlobar fissures. Small leaks close spontaneously within 5-7 days; larger leaks may persist longer and could be associated with increased morbidity and prolonged hospitalization. We evaluated the role of different techniques to complete interlobar fissures before pulmonary lobectomy to prevent postoperative air leaks and reduce hospital stay and costs. METHODS: A total of 30 patients undergoing pulmonary lobectomy for lung cancer and presenting incomplete interlobar fissures that needed to be opened both anteriorly and posteriorly were randomized into three groups. In Group I, fissures were created with a GIA stapler and buttressed with bovine pericardial sleeves. In Group II, we used TA 55 staplers alone; in Group III we used the 'old fashion' cautery, clamps and silk ties. The three groups were homogeneous for age, type of pulmonary resection and stage of the tumor. The duration of postoperative air leaks and hospital stay were compared with the one-way variance analysis. RESULTS: Postoperative air leaks for Groups I, II and III persisted for 2 +/- 0.94, 5.3 +/- 2 and 5.3 +/- 1.7 days, respectively. Mean hospital stay was 4.4 +/- 0.96, 7.8 +/- 2.14 and 7.2 +/- 1.5, respectively. The difference between groups in terms of duration of postoperative air leaks and hospital stay was statistically significant (P = 0.0001). CONCLUSIONS: The use of GIA staplers and pericardial sleeves to complete interlobar fissures for pulmonary lobectomy significantly reduces the duration of postoperative air leaks and hospital stay; no complications were associated with this technique.

Safety and efficacy of bronchovascular reconstruction after induction chemotherapy for lung cancer.

OBJECTIVE: The aim of this study was to ascertain the safety and efficacy of bronchial sleeve resection and reconstruction of the pulmonary artery in patients who had undergone induction chemotherapy for lung cancer. METHODS: Between January 1991 and July 1996, we operated on 68 patients who had received three cycles of cisplatin-based induction chemotherapy. In 27 of these cases, we performed a lobectomy (n = 25) or bilobectomy (n = 2) associated with reconstruction of the bronchus, the pulmonary artery, or both. In only five additional patients, pneumonectomy had to be carried out. Before chemotherapy, 14 patients were in stage IIIA and 13 were in stage IIIB. All patients in stage IIIB had T4 disease; no N3 cases were included. At thoracotomy, one patient had no evidence of tumor, six were in stage I, 13 were in stage II, six were in stage IIIA, and one was in stage IIIB. Sixteen patients had epidermoid carcinoma and 11 had adenocarcinoma. RESULTS: Sixteen patients underwent bronchial sleeve resection; 11 had various types of pulmonary artery reconstruction, associated with the bronchial sleeve in eight cases. In 26 patients, resection was radical with histologically negative margins. Neither bronchial complications nor deaths occurred. One patient had empyema and two had wound infections. Mean chest tube duration was 6 days. After a postoperative follow-up of 4 to 69 months (mean 25 months), 14 patients are alive and free of disease, one is alive with disease, and 12 have died. There were no local recurrences. The 1- and 4-year survival rates are 78% and 39%, respectively. CONCLUSIONS: Although it is technically demanding, lobectomy associated with bronchovascular reconstruction is feasible, with good immediate and long-term results, after induction chemotherapy.

Occult lung cancer in patients with bullous emphysema.

BACKGROUND: The incidence of lung cancer is increased in patients with bullous emphysema. METHODS: A series of 95 patients undergoing excision of bullous lung tissue was reviewed to determine the incidence and long term outcome of occult carcinoma present in the resected material. RESULTS: Four patients (4.2%) had peripheral foci of large cell carcinoma in the resection specimen (three bullectomies and one lobectomy). CONCLUSIONS: Resected bullous lung tissue should be carefully examined for areas of bronchogenic carcinoma. The results of incidental complete excision are favourable.

Ambulatory mediastinal biopsy for hematologic malignancies.

OBJECTIVE: We retrospectively evaluated our experience with outpatient surgical biopsy of mediastinal lesions in patients with hematologic malignancies, its cost-effectiveness and ability to allow diagnosis. METHODS: Eighty patients underwent outpatient surgical biopsy of mediastinal lesions related to hematologic malignancies (50 cervical mediastinoscopies, 24 anterior mediastinotomies and six video-assisted thoracoscopies). Eight patients had a superior vena cava syndrome, five had lesions residuing or relapsing after chemo-radiotherapy and six and had been treated with steroids before diagnosis; in five cases the biopsy had been previously performed at other hospitals without achieving a positive diagnosis. RESULTS: Ambulatory mediastinal biopsy allowed diagnosis in all cases. Fifty-one patients had Hodgkin disease, 28 had non-Hodgkin lymphoma and one had chronic lymphatic leukemia. There was no operative mortality. Complications were: pneumothorax and bleeding during mediastinoscopy and wound infection after anterior mediastinotomy. CONCLUSIONS: Mediastinal biopsy can be safely performed on an outpatient basis in selected patients with mediastinal involvement due to hematologic malignancies. Costs were markedly reduced with respect to in-hospital procedures.

Multimodality treatment of thymoma: a prospective study.

BACKGROUND: Thymomas are a heterogeneous group of tumors. Treatment of invasive lesions is not well standardized. The aim of this study is to propose a clinicopathologically based protocol for multimodality therapy. METHODS: Between 1965 and 1988, we operated on 83 patients with thymoma who did not receive standardized adjuvant therapy. In 1989, on the basis of the retrospective analysis of the data, we started a multimodality therapy protocol and used it for 65 patients. Twelve patients had medullary thymoma (11 stage I and 1 stage II), 13 had mixed type (6 stage I and 7 stage II), and 40 had cortical thymoma (4 stage I, 11 stage II, 12 stage III, and 13 stage IV). We considered three groups. Group I (n = 18 patients), benign thymoma, included stage I and II medullary and stage I mixed thymomas; radical resection with no adjuvant therapy was performed. Group II (n = 22), invasive thymoma, included stage I and II cortical and stage II mixed thymomas; postoperative chemotherapy plus radiotherapy was always administered. Group III (n = 25), malignant thymoma, comprised stage III and IV cortical thymomas and stage III mixed thymomas; resectable stage III lesions were removed, and highly invasive stage III and stage IV lesions underwent biopsy, neoadjuvant chemotherapy, and surgical resection; postoperative chemotherapy and radiotherapy was administered to all patients. RESULTS: The 8-year survival rate for patients in stages I, II, III, and IV was 95%, 100%, 92%, and 68%, respectively. Patients with medullary thymoma had a 92% 8-year survival rate; those with mixed type, 100%; and those with cortical thymoma, 85%. Group I had an 8-year survival rate of 94%; group II, 100%; and group III, 76%. Survival was compared with that of patients operated on before 1989: differences were not significant for group I; survival improved in group II (100% versus 81%; p = not significant); and group III showed significant improvement (76% versus 43%; p < 0.049). CONCLUSIONS: Multimodality treatment with neoadjuvant chemotherapy and adjuvant chemotherapy plus radiotherapy may improve the results of radical resection and the survival of patients with invasive and malignant thymoma.

[The selection of patients who are candidates for lung transplantation]. / La selezione dei pazienti candidati al trapianto polmonare.

From January 1991 to September 1993 we evaluated 49 patients (27 males and 22 females--mean age 42 years) with chronic respiratory failure as possible candidates for lung transplantation. 27 patients had idiopathic pulmonary fibrosis, 9 emphysema, 4 bronchiectasis, 3 cystic fibrosis, 3 primary pulmonary hypertension and 1 respectively lymphangiomatosis, thromboembolism and vanishing lung. 16 patients were considered suitable for single or double lung transplantation. 4 patients died waiting, 4 underwent single lung transplantation and 8 are still on the waiting list. The mean survival of patients in the waiting list was 145 days (52 for patients with idiopathic pulmonary fibrosis), ranging between 35 and 398 days.

Report of a case of video-assisted thoracoscopic resection of bronchogenic cyst developed in the aorto-pulmonary window.

We report the case of a 28-years-old male with a bronchogenic cyst developed in the aorto-pulmonary window. Left video-assisted thoracoscopy was performed and the cyst was removed intact and completely. Operative time was 48 minutes. The postoperative course was uneventful and the patient was discharged on the third postoperative day. We believe that an uncomplicated mediastinal bronchogenic cyst can be successfully approached by video-assisted thoracoscopy. In the case of an intraparenchymal or complicated cyst, thoracoscopic resection can be technically difficult and hazardous, and open approach is preferable.

[Video-assisted thoracoscopy in the treatment of recurrent pneumothorax]. / La toracoscopia video-assistita nel trattamento del pneumotorace recidivante.

Between April 1992 and May 1994, 45 patients with recurrent spontaneous pneumothorax underwent videoassisted thoracoscopy (group I). The mean chest tube duration, the length of hospital stay, the use of parenteral narcotics, the complications and the follow-up were analyzed and compared to the same data of a group of 21 patients previously treated by open approach between January 1991 and March 1993 (group II). Average age, sex and surgical indications distribution were comparable (group I: 36 males, 9 females, mean age 31.7 years; group II: 17 males, 4 females, mean age 31.5 years). Mean chest tube duration was lower in group I (group I 4.3 days vs group II 7.2 days), as was mean hospital stay (group I 4.6 days vs group II 10.3 days) and the necessity of parenteral narcotics for pain relief (group I 11% vs group II 66% of patients). No episodes of relapsing pneumothorax occurred in either group of patients after a mean follow-up of 12.4 months (range from 1-24 months) for group I and 30 months (range from 24-36 months) for group II. The incidence of minor complications was less in group I (4.4%) than group II (23.8%). Our early results in the treatment of recurrent spontaneous pneumothorax by videoassisted thoracoscopy have been encouraging and the merits of this approach make it preferable to thoracotomy.

Preoperative chemotherapy and immunochemotherapy for locally advanced stage IIIA and IIIB non small cell lung cancer. Preliminary results.

From January 1991 to November 1993, 110 patients with histologically confirmed stage IIIA and IIIB non-small cell lung cancer (NSCLC), were seen at our Institution. Our study was designed to evaluate whether redirection to surgery of otherwise unresectable patients may be obtained by preoperative therapy. Forty-nine patients were considered eligible for neoadjuvant treatment. Thirty-two (Group I) were treated with two or three cycles of cisplatin, vinblastine and mitomycin C and 17 (Group II) received two cycles of cisplatin, VP16, alpha 1 timosine and interferon. The overall response rate was 81.2% for Group I and 88.7% for Group II. Downstaging was predictive of resectability (P < 0.05). Forty-one patients (83.6%) underwent thoracotomy with 37 (75.5%) radical resections. Conservative techniques (bronchovascular reconstruction) (22 cases) were preferred over pneumonectomy (2 cases). The resectability rate was 84% for Group I and 87% for Group II (P = NS). Treatment-related complications were minor, with no deaths. Postoperative complications occurred in two cases in each group (7.4% and 14.3%). There was no histologic evidence of tumor in three patients. Two-year survival was 75% for Group I and 55% for Group II (P = NS). To date 35 patients who had complete resection are alive, and free of disease. We conclude that preoperative chemotherapy produces high response and resectability rates in both stage IIIA and IIIB unresectable NSCLC; radical resection using a conservative technique is possible in patients who are otherwise unresectable; no local recurrence occurred after radical resection; no significant differences were demonstrated between the two protocols.

Pancytopenia associated with thymoma resolving after thymectomy and immunosuppressive therapy. Case report.

In a 43-year-old woman, pancytopenia accompanying thymoma persisted after thymectomy, requiring weekly blood transfusions, and did not respond to prednisone 50 mg/day. Cyclosporine 10 mg/kg/day plus prednisone 20 mg/day for a month gradually corrected the blood parameters. Thirty months later the patient is well and haematologically stable.

Preliminary results of a complete study protocol on synthetic vascular graft healing and its complications.

The microscopic and anatomic features and bacteriologic culture results of different portions of single, explanted dacron synthetic vascular grafts (SVG) were studied together with patient clinical data. With this complete study protocol a better understanding of the healing process and its associated pathology can be achieved. We studied three, amply distanced graft portions from each of five patients (15 total graft portions) undergoing revision for infectious and non-infectious reasons. We divided the SVG portions studied into a Group 1, with high degrees of graft healing and into a Group 2, with both infection-dependent, early healing complications and perigraft chronic inflammatory reaction-dependent, late healing complications. These late healing complications were found dependent upon a host vs graft reaction. This study confirmed in humans the important role of an internal and external fibrotic graft incorporation in the definitive healing of a SVG. A host vs graft reaction was suggested to be an alternative to the frequently cited low virulent infection pathogenesis of late SVG healing complications. A sure definition and treatment of late SVG healing complications will only be established by means of a complete study protocol performed on a large number of explanted SVGs.